Please complete the form below. Alaska HMIS staff will respond to requests within two business days with the estimated product delivery date. Please understand that, depending on the complexity of the report request, it can take up to 30 days for delivery, so please plan your report request accordingly. Report delivery times will vary depending on priority requests and other outstanding projects.

Basic Information

Name *

Name

First Name

Last Name

Agency *

Phone Number *

Phone Number

(###)

###

####

Email Address *

Taskforce/Workgroup

Does your agency currently use Alaska’s HMIS? *

Requested Report Delivery Date (could take up to 30 days) *

Requested Report Delivery Date (could take up to 30 days)

MM

DD

YYYY

Report Details

Is the data request for a specific grant? *

If the request is for data that will be used to complete a grant application, you must send a copy of the application to akhmis@icalliances.org with the title 'Grant Application to Accompany Custom Data Request.'

Grant application due date (if applicable)

Grant application due date (if applicable)

MM

DD

YYYY

What will this report be used for? *

Please provide specific details.

Which HMIS Provider(s) should be included in the report? *

Please provide as much of the following as possible: Provider Name, Provider ID Number, Program Name (if applicable), ServicePoint workflow type (Entry/exit, Service Transaction, or Shelter Stays)

Data elements or assessment questions to include: *

What do you want the report to count? *

What do you want the report to list? *

Report Start Date *

Report Start Date

MM

DD

YYYY

Report End Date *

Report End Date

MM

DD

YYYY

Provide any additional details that need to be included on the report

Thank you!

Please remember: If your request is related to a specific grant application, you must send a copy of the application to akhmis@icalliances.org with the title 'Grant Application to Accompany Custom Data Request.'